Friday, June 24, 2011

Apres le Deluge: The CEJA Spin Cycle Begins

When the AMA adopted the 5th version of the CEJA report on industry-funded CME, it seemed clear that this was an ominous and very bad sign for the future of industry-funded CME. I already posted my take on the report here (short version: say goodbye to most industry CME). Now we are beginning to see how industry supporters are responding. Basically, they are saying, or maybe just desperately hoping, "Feh! It's no big deal."

They were singing a different tune before the vote. As was true for the prior CEJA CME reports, MECCs (medical education communication companies) and their supporters maligned the document. The Alliance for CME, the main trade organization for MECCs, had released this statement recommending that many sentences in the recommendations be stricken—essentially any sentence that challenged the status quo.

ACRE, a relatively new organization composed of physicians who vigorously defend financial relationships with drug companies issued what amounted to a white paper calling for the rejection of the report. ACRE found so many things wrong with CEJA 5.0 that its critique ran three pages longer than the report itself.

A couple of weeks before the vote, Medical Meetings magazine published an editorial by columnist and MECC owner Stephen Lewis angrily attacking CEJA as being an “oxymoron” because it “seems to have forgotten the critical link that exists between ethics and evidence.”

And five days before the vote, Thomas Sullivan, the owner of the MECC Rockpointe, who writes the influential pro-industy blog Policy and Medicine, reviewed and agreed with the Alliance for CME’s position that the CEJA report be canned.

So much for the run up. Now that the report has been adopted, industry advocates appear to be quickly distancing themselves from these prior alarmist views about CEJA.

Two days after the vote, Thomas Sullivan was almost celebrating. Headlined “AMA CEJA 2011: AMA House of Delegates Approves Report – Now Emphasis on Value of CME in Patient Care,” his post was nonchalant. Far from seeing this as a threat to industry funding, Sullivan now argued that the report “merely reflects an alignment of AMA policies on CME with the ACCME, HHS OIG, and the PhRMA and AdvaMed Code of Ethics. Commercial support of CME will still remain a valuable resource for CME providers to help keep physicians up to date on the latest breakthroughs and treatments.”

Medical Marketing & Media, a publication financially dependent on pro-industry stakeholders, published an article that appeared to be journalistic coverage of the decision but which was essentially an editorial saying "don't worry, be happy." The article emphasized that CEJA 5.0 does not call for an “all out ban” on industry funding, but instead “places the moral onus on physician presenters to disclose to learners their financial interests in the topic they are speaking about.”

Derek Warnick, an industry CME director and blogger, responded with an entertaining and thoughtful post in which he concludes that “If I had to guess (OK, I don’t HAVE to guess, but I’m going to anyway), I would say that CME providers may be asked to provide a little more documentation about faculty selection and conflict resolution processes, but I don’t anticipate any major shake-ups.”

Meanwhile, the only person whose opinion anyone cares about has remained silent. That would be Murray Kopelow, the director of ACCME. If you email ACCME for his response (as I did) you will receive the following official statement: “We are currently reviewing the CEJA Recommendations and the Board of Directors will be deciding on any next steps.” The next board meeting is July 21 in Chicago, so we will probably not get any response until they publish their Executive Summary of that meeting, probably a month or so after it occurs.

Your characterization of the Alliance for CME as “the main trade organization for MECCs” is both inaccurate and unfair. The MECC trade organization is NAMEC as you well know. The Alliance is a professional organization that is open to all members of the profession and has a broad array of special interest groups, including one for MECCs. What is most distressing is that you clearly know all of this, and I know that you know it. You are deliberately distorting what you know to be true because you disagree with the position that the organization took on this issue at the expense of less informed readers. You have a strong point of view and it is one that I can respect so long as you make your arguments without twisting the facts.Shame on you!

Anonymous--I stand corrected. You are right that the Alliance is not exclusively a MECC trade organization. It is certainly by far the largest CME trade organization, with 2300 members. The Alliance was founded in 1975; NAMEC was founded in 2002 by four MECCs. I have no idea how many members it has, but I would place bets that the Alliance has overwhelmingly more MECC members. And although the Alliance includes plenty of medical societies, AMCs, and other members, in terms of advocacy it speaks with one voice--always in favor of industry funding of CME. I and many others view it primarily as an organization catering to the needs of MECCs. I may be wrong--obviously you strenuously disagree.

But why are you so irate about identifying the Alliance with MECCs, anyway? Do you feel that they damage your organization's reputation?

Deeds, not words are what define us, true? I would be interested what your opinion is of the post made over at PsychCentral by John Grohol re this Psych Inpt unit in Massachusetts, reported in the Boston Globe, that fired all their staff in response to several reports of abuse of patients.

Really, fire everyone except upper level administration? Seems to be similar to the policies of our AMA and APA organizations. "Do as we say, not as we do."

How do you people of substance and character of responsibility and integrity belong to these organizations!?

It amazes me that psychiatrists, ostensibly trained and charged with understanding human cognitive processes, social behaviors, development of subjective emotional experience, and the unconscious, pretend to be unaware of the expected and logical results of influence.

It is easy to argue the absence of direct linear results where they may be less obvious (although it is clear these gains - enormous financial gains - exist and are ubiquitous in our capitalist profit oriented health care system). But what galls me is having to even make arguments to other scientists of the mind about the obvious scandalous results of pervasive dynamics of influence within the core of the systems that develop medications, promulgate their use and educate physicians about indications, alternatives, risks, benefits and side effects.

I do not speak for the Alliance although I am a long time member and volunteer. You started with representing the Alliance as a MECC trade association, and when challenged backed off to a position of “they’re MECC-dominated so it amounts to the same thing anyway.” While opinion seems to be the main thing on offer here, facts can sometimes be helpful. I contacted the Alliance staff for current membership demographics and here they are:Federal Health Care Educators 1%Health Care Education Associations 6%Hospitals and Health Systems 27%Medical Education Communication Companies 18%Medical Schools 13%Medical Specialty Societies 16%Pharmaceutical, Biotech, Device 9%State Medical Societies 2%Other 8%I also reviewed the Board membership and there is only 1 MECC-affiliated member represented.Yes, MECCs membership is significant, but hardly dominant.Before you conclude that MECC influence bullied the Board into taking a MECC-friendly position, perhaps you should consider that industry currently supports half of the CME at the US and that an abrupt change would be very disruptive to the entire system, not just MECCs.You can count me among those who are uncomfortable with this arrangement, but unless we replace the income from somewhere the result will be collapse, not reform. The obvious source should be from the physicians themselves, but the recent survey published in the Archive of Internal Medicine (Tabas et al, May 9, 2011) make it clear that at this point the physicians aren’t willing to pay.

Anonymous, Thanks for your figures and your correction of my incorrect statements. The numbers speak for themselves: If only 18% of the Alliance membership is MECCs, it clearly is not MECC-dominated. I have been guilty of implying that MECCs are responsible for most industry-funding of CME, but clearly medical societies and hospitals share the "blame."

I will quibble with your descriptions of the results of the Tabas study. Here is the relevant passage from the study you are referring to:

"Although respondents frequently perceived bias from com-mercial support, they were split (169 of 369 physicians[46%], 125 of 307 others [41%]) on whether increasingregistration costs would be an effective way to decrease thatsupport."

Furthermore, physicians in this study were never asked the question, "Would you be willing to pay extra for CME if it were not funded by industry?" Instead they were asked to what extent they agreed with the statement: "Raising registration fees is an effective way to decrease pharmaceutical/medicaldevice company support."

Physicians rated their agreement with the statement on 5 point Likert scale. 46% of physicians said they "strongly or somewhat agreed" with the statement (4 or 5 on the scale), while 54% "strongly or somewhat disagreed or were neutral". The authors didn't report what percent were neutral, but clearly placing neutral into the "disagree" category affected the way the study was interpreted.

Given this, I do think you are going out on a limb when you say the study results "make it clear that at this point the physicians aren’t willing to pay."

Not only was this question never explicitly asked, but at least half of the respondents strongly agreed, somewhat agreed, or were neutral about the proposition that increasing reg. fees would be effective in decreasing industry support.

In fact, if you don't mind getting your cme online or via subscription newsletters, the going rate for non-industry-supported CME is about $10/hour, more or less. That's only $250/year for the required 25 hours in most states. Physicians are clearly willing to pay this, because they already are.

In the spirit of disclosure and full transparency you should explicitly state in your every posting the following: "If industry-sponsored CME goes away, I, Daniel Carlat, M.D., will make more money. My position on medical education is clearly driven, at least in part, by a profit motive."

I'm glad you enjoyed my blog post. To be clear, I am not an "industry" CME Director' but rather the CME Director for a medical education company. In my world, "industry" generally refers specifically to the pharmaceutical industry, where I most definitely have never been employed. Thanks!

The percentages and characterizations of how many physicians do or don't want to pay more for CME can be debated all day. What's not up for debate though, is that alot of them don't want to pay more. Will everyone be better off if physicians are cramming in more free online CME just to save money? What's to say they wouldn't just rely more on non-CME, industry-provided data instead?

Like it or not, industry funding facilitates quality education. Yes there can be bias, but yes there are plenty of people with integrity in CME who work tirelessly to keep it out. It seems the implication is that industry funding comes with inherent bias attached -- this is just not true in the practical delivery of many CME programs.

However, it's also not true that there couldn't be an alternative model. I just haven't heard it yet, especially from this blog. Raising registration fees across the board and shifting all the cost to physicians is NOT a realistic alternative.